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Promethazine-Chlorpromazine Combination in the Treatment of Unmanageable Psychotic Patients Armando R

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Promethazine-Chlorpromazine Combination in the Treatment of Unmanageable Psychotic Patients Armando R Henry Ford Hospital Medical Journal Volume 17 | Number 4 Article 10 12-1969 Promethazine-Chlorpromazine Combination in the Treatment of Unmanageable Psychotic Patients Armando R. Favazza Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal Part of the Chemicals and Drugs Commons, Life Sciences Commons, Medical Specialties Commons, Psychiatry and Psychology Commons, and the Public Health Commons Recommended Citation Favazza, Armando R. (1969) "Promethazine-Chlorpromazine Combination in the Treatment of Unmanageable Psychotic Patients," Henry Ford Hospital Medical Journal : Vol. 17 : No. 4 , 305-310. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol17/iss4/10 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp. Med. Journal VoL 17, No. 4, 1969 Promethazine-chlorpromazine Combination in the Treatment of Unmanageable Psychotic Patients Armando R. Favazza, M.D.* Administering a combination of promethazine and chlorpromazine to patients with a "galloping psychosis" has an antipsychotic and tranquilizing effect which calms them down to a more manageable and less aggressive state. The drugs are chemically similar; promethazine's actions are strongly potentiated in the combina­ tion, so large doses must be given under careful supervision. Case histories demonstrate successful short term management of acutely psychotic, aggressive patients who were a danger to themselves and others. Acute, intense psychotic episodes common in the author's experience for can pose difficult problems for both some patients to receive massive doses the patient and those who care for him. (up to 3 grams a day) and yet remain Use of trifluoperazine may aggravate psychotic and unmanageable. During such patients, while thioridazine and these episodes of "galloping psychosis" haloperidol cannot be given parenteral­ patients may be abusive to themselves ly. Most commonly used drug in treat­ and others, unable to follow orders, to ing such patients is chlorpromazine; eat or rest, and frightening to other because of its great ability to calm pa­ patients. In the past such patients who tients, its relative safety in large doses, were obviously out of control were its availability in both oral and paren­ placed in seclusion rooms and/or teral forms, and also because most given electroshock. In many institu­ physicians are familiar with it. tions, however, electroshock is not fre­ While most patients can be brought quently resorted to, and seclusion under rapid control with chlorproma­ rooms have been abandoned in favor zine alone, there are some who seem of a combination of a better trained to resist this treatment. It is not un- and more abundant staff, a well con­ ceived milieu, and modern drugs. But when the usual drugs and milieu fail, *Department of Psychiatry, Univ. of Mich­ even the best trained staff may have igan. difficulty handling patients in whom a Presented at the Resident Education Semi­ psychotic process rages unabated. For nar, Henry Ford Hospital House Staff As­ such patients the author has found ef- sociation, May 17, 1969. 305 Favazza fective a combination of promethazine Laborit, the French surgeon, at­ (Phenergan) and chlorpromazine. tracted great attention to the drug in The chlorpromazine is used for its the early 1950's with his papers on its anti-psychotic and tranquilizing effects. use in artificial hibernation.! •'^ The Whether chlorpromazine affects symp­ drug has also been widely used in sleep toms alone or has a direct effect on therapy.* " For psychiatric use prome­ some psychotic processes, it appears to thazine has not been found to be as be beneficial in causing these chaotic effective as the other phenothiazines^ episodes to abate. The physician cer­ despite some early enthusiasm.'' In tainly would be remiss to withhold the 1958 Shea et aP wrote: drug or another like it. "The data suggests that promethazine Promethazine, marketed primarily unlike other phenothiazine derivatives as an anti-histaminic, is used because when administered intravenously in of its ability to slow down the patient relatively large concentrations may in­ rapidly so that he can be cared for. duce a depression of both cortical and The manufacturer's package insert subcortical centers. In view of this ac­ notes that promethazine "relieves ap­ tion the drug would seem to have con­ prehension and produces a light sleep siderable therapeutic value in the man­ from which a patient can be easily agement of those patients with in­ aroused" (the manufacturer specifi­ creased psychomotor activity not clin­ cally notes this is conjunction with ically controlled by either promazine nighttime surgical or obstetrical seda­ or chlorpromazine." tion). Promethazine's actions are strongly Promethazine is a phenothiazine de­ potentiated when administered with rivative and is chemically similar to chlorpromazine. In moderate doses it chlorpromazine. (See below.) makes a patient feel fatigued or sleepy and greatly slows him down. In large doses it can put a patient to sleep. It is possible to regulate the medication so that a patient achieves a light sleep from which he can be awakened easily to eat, drink, void, breathe deeply and take short walks. The state of sleep can be so regulated that the patient will respond to questions so that the progression or diminution of the psy­ chotic episode can be roughly gaged. One or two doses of promethazine can be withheld if the patient is sleeping so deeply as to make evaluation of his mental state impossible. Barbituates, PROMETHAZINE CHLORPROMAZINE because of their depressing effect on HYDROCHLORIDE HYDROCHLORIDE medullary centers and their tendency to induce deep sleep, are not satisfac­ tory substitutes for promethazine. 306 Promethazine-chlorpromazine in Treatment of Psychotic Patients Case Reports A typical six-hour period is charted: The following cases demonstrate the combined use of promethazine and CHART NUMBER ONE chlorpromazine. HOURS 8 A.M. 9 A.M. 10 A.M. 11 A.M. 1^ Noon 1 P.M. 2 P.M. Blood Pressure 110/80 Case Number 1 Chlorpromazine 300 r^g Promettiazine The patient was a 17-year-old girl who Trihexylphenidyl 4 mg first became psychotic while visiting a for­ Awake eign country as an exchange student. She & Agitated was immediately flown back home and ad­ & walking mitted directly to University Hospital. After SlTroggy appearing to restitute, for no discernible Dozing Asleep & reason, she became progressively and se­ Arousable X verely psychotic. For 36 hours she did not sit down or eat. She was unable to fol­ HarO lo Artiuse low orders. She talked loudly about natural Onarousable and supernatural spirits, the purity of her Comments Qreakfast crying took cnangeo Lunch riuids pajamas blood, and the secrets of the universe which sat in self she alone understood. She carried a hair­ 1 lioir brush and hit anyone near her. She rushed into the nursing station several times at­ tempting to rip the phone out of the wall. The patient was maintained in this state The other patients became frightened and for 10 days. On several occasions she re­ relayed their anxiety to the staff. As fairly fused to take her medications orally and standard procedure the patient received 50 they were then given intramuscularly. Her mgs of intramuscular chlorpromazine for room door was kept open at all times and, three doses, 30 minutes apart. This had no while other patients could look in, they effect except that she finally agreed to take were not allowed to visit. Her treatment oral medication rather than be held down was discussed at the patient-staff conference. for an injection. She then received hourly A nurse, aide or physician checked the pa­ doses of medication, but seemed unaffected tient every 30 minutes, and her mental by the high dose of 2500 mgs in 24 hours. status was roughly evaluated by the physi­ Her blood pressure and physical state were cian several times daily. Even while she closely monitored. Her psychosis appeared was under the influence of all these medi­ to worsen. The addition of 20 mgs of tri­ cations, it was possible to determine easily fluoperazine only seemed to heighten her at the end of 10 days that her psychosis agitation. Finally, after 500 mgs of a bar- was lessening. Her medication was reduced bituate was given intramuscularly, the pa­ by one-half for a four-day period, then by tient fell asleep. one-half again for four more days. Finally the promethazine and trihexyphenidyl were In six hours, she awoke, and if anything, eliminated and the patient continued on she was more unmanageable. All attempts low doses of chlorpromazine. by staff to handle her failed. Finally she was started on a regimen of 50 mgs prome­ Case Number 2 thazine orally every four hours and 300 mgs chlorpromazine orally every four hours. The patient was a 43-year-old male with The doses were so administered that she a long history of mental illness. He had received one medication or the other every received ECT 20 years ago and insulin two hours. Before each dose her physical shock therapy six years ago. Eight months and mental status were evaluated. She also previously he was diagnosed as a manic- received eight mgs of trihexyphenidyl (Ar- depressive at a state mental hospital and tane) daily. Within several hours the pa­ was treated with massive doses of chlor­ tient went into a light sleep. She could be promazine (2500 mg a day) for his "mania." aroused easily. She was able to eat and to At this time he was quite paranoid and void. With help she could walk to the bath­ was threatening people with an axe. He room and even brush her teeth. A nursing presented a serious management problem chart was set up and faithfully maintained.
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